Cancer in Pregnancy: Nutritional problems in women with cancer during pregnancy

Introduction
The recommended caloric intake during pregnancy increases by 300 kcal/day above non-pregnant values, with increases of 100 kcal/day in the first trimester, and 300 kcal/day thereafter. The higher caloric requirements of pregnancy enable the pregnant woman to achieve the requisite weight gain associated with normal pregnancy. However, a wide range of values for both weight gain (i.e., average 12.5 kg or 25-30 lb) and pattern of weight gain (@ 0.45 kg or 1 lb per week in later pregnancy) are compatible with normal pregnancy outcome. The components of the weight gain of pregnancy are the feto-placental unit and uterus, total body water, blood volume, breast tissue, and fat stores (used for milk production and as a source of calories during breastfeeding). There are many reasons for decreased nutritional intake during pregnancy among women with cancer: the effects of the cancer itself, the cancer treatment, and/or the stress of having been diagnosed with cancer. Different patients will experience problems to different degrees.

Impact of poor nutrition on pregnancy outcome
Although simple starvation and cancer cachexia are not equivalent states, literature on the former will be reviewed in order to examine the relationship between poor oral intake and pregnancy outcome. Even severe famine has not been associated with an increased incidence of congenital malformations or perinatal mortality . However, a consistent pattern of weight loss or failure to gain weight has been associated with decreased fetal growth. The relationship is not necessarily predictable in the individual patient.

It is impossible to be totally reassuring about the impact of starvation ketosis on neurological and psychological development, given data from the Dutch Hunger Winter and outcomes of diabetic pregnancies. However, given that diabetic ketoacidosis cannot be equated with starvation ketoacidosis, and the Dutch Hunger Winter was a severe famine associated with prolonged intakes of less than 100 kcal/d, concerns about the impact of poor oral intake on neurodevelopment remain primarily theoretical.

Nutritional assessment and management of the patient with cancer in pregnancy
Patients with cancer in pregnancy should be referred to a dietician for detailed nutritional assessment as clinical signs of undernutrition are insensitive. Assessment of fetal growth should be conducted clinically by symphysis-fundal height, and also by serial ultrasonographic measurements. Although the usefulness of nutritional support in improving maternal prognosis is controversial, potential risks of under-nutrition to the fetus warrant maternal nutritional support of the pregnant patient with cancer.

General dietary recommendations
General dietary recommendations vary, but include advice to eat small, frequent meals, eat whatever appeals to them, eat cold food instead of hot (which is more aromatic), avoid strong cooking odours, and drink fluids frequently but between meals. For patients who cannot maintain nutritional intake, food supplements which provide calories and protein may be used. A dietician can advise patients in detail about the content of their diet.

If the patient is unable to maintain nutrition for a prolonged period of time (i.e., certainly greater than 7 days), then consideration should be given to enteral (especially in the absence of vomiting) or parenteral feeding. Both have been required and used successfully in pregnancies complicated not only by cancer, but also by other conditions such as NVP and primary gastrointestinal disorders.

Standard complications of these management approaches do not appear to be increased in pregnancy. In pregnant patients with cancer, one must also consider effects on the gastrointestinal tract by the cancer itself and/or systemic chemotherapy. In patients with mucositis, foods of extreme temperature, texture (i.e., very hard or chewy), acidity (e.g., orange juice), or spiciness are best avoided; patients may use topical anaesthetic mouthwashes safely.

The safety of anti-emetic medication during the first and early second trimesters of pregnancy also comes from the NVP literature, and the reader is referred to the section entitled, "Anti-emetic therapy for NVP". Diarrhea may be relieved by reducing fibre intake (especially fruits and vegetables) and increasing fluid intake (to at least 8-10 large glasses of liquids daily); short-term use of anti-motility agents (e.g., diphenoxylate/atropine, or loperamide) may be considered if diarrhea is severe and not associated with hematochezia. Conversely, patients with constipation (especially due to narcotics) may find increasing the fibre in their diet and increasing their fluid intake useful.

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